In 1995, delegates to the American Nurses Association (ANA) convention stated once again that a baccalaureate degree should be the minimum requirement for registered nurse licensure. Originally proposed by the ANA in 1965, nurse leaders and educators in the United States have not mandated one entry level, a baccalaureate degree, for entry to professional nursing practice. Yet nurses in the U.S. are not alone in encountering impediments, as their system of education moves from Nightingale-inspired, hospital-based diploma programs to university-based degrees. Appreciation of recent international developments in nursing education may provide generalized collégial support for timely educational reform within the United States and facilitate global understanding among nurses. This paper summarizes the history and current status of nursing education in four English-speaking countries: Australia, New Zealand, the United Kingdom, and the United States of America. Because of differences in nomenclature among the four countries, care has been taken to define institutions and educational programs. Furthermore, to facilitate a broad assessment of nursing education in each country, a summary of the principal academic sites and duration of the programs is provided (Table).
AUSTRALIAN NURSING EDUCATION
The Nightingale model of nurse training was introduced into Australia in 1868 by Lucy Osburn, a Nightingale trainee, at what was then the Sydney Infirmary. Initially, the Australian Trained Nurses Association and the Victorian Trained Nurses Association controlled nurse training. Members of these organizations were very successful in standardizing and improving nurse training programs and introduced a register of trained nurses. During the 1920s and 1930s, statutory authorities were introduced to control nurse training throughout Australia (Russell, 1990). The functions of these statutory authorities included supervising nurse training and accrediting hospital-based nurse training schools. These authorities also maintained a register of trained nurses and conducted state-wide registration examinations.
Principal Academic Venue and Length of Prereglstration Nursing Programs
Until the 1960s, this pattern of nurse training, subject to government control and regulation, continued across Australia (Russell, 1990). In addition, a variety of specialist preregistration nursing courses were developed. For example, during the 1960s in New South Wales there were six areas in which registration as a separate certificate or license to practice was approved by the Nurses' Registration Board: general, psychiatric, geriatric, mental retardation, midwifery, and mothercraft nursing. Similar patterns developed in all other states although the states differed in the areas they approved for registration. However, the general nursing course still provided the basis for other post-basic specialist training and was available in all states.
In the 1960s and 1970s, the nursing profession in Australia passed through a period of industrial and professional turmoil leading to many significant changes. This turmoil is well demonstrated by the plethora of expert committees and workshops that were established, both by the government and the profession itself, to investigate various aspects of nursing. All these reports contained many, and often conflicting, recommendations on how the ills besetting the nursing profession and its educational preparation could be remedied. The reports were widely circulated and discussed both inside and outside the nursing profession.
It was during this period that the appropriate venue for nurse education began to be seriously reconsidered. Arguments were being advanced to retain the current hospital-based apprenticeship system, or to transfer this education into colleges of advanced education either totally or in part; or to establish nurse education at the university level; or any combinations of these. The newly developed colleges of advanced education provided undergraduate, vocationally-oriented diploma programs that were strongly linked to industry. It was also during this period that a number of new patterns of nurse education began to emerge. These new patterns included the development of regional schools of nursing, combined degree and nursing courses, and pilot nursing programs within a number of colleges of advanced education (Russell, 1990).
Changes to nursing and nurse education were influenced by multiple factors: nurses' changing role; developments taking place in nursing and nurse education overseas, particularly in the United Kingdom and the United States of America; the increasing cohesiveness between the various nursing organizations within Australia; and general social concerns. The latter included the changing role of women within society, government initiatives, or lack thereof, and ongoing funding constraints (Russell, 1990).
In 1984, the Federal Government of Australia announced its support for the transfer of basic nurse education into the higher education sector. Members of the nursing organizations, who had worked so hard and long to achieve a national decision, received this announcement with jubilation. Dr. Margretta Styles, then president of the International Council of Nurses, stated: The world of nursing, and I mean literally the world of nursing watches you with wonder and awe and hope as you revolutionize your system of basic nursing education" (Styles, 1990). This transfer has occurred at varying rates in each state and territory with the last intakes into hospital-based programs being as late as 1990 in Queensland (Nursing Education, 1994). The federal government also agreed to become responsible for funding these programs across Australia.
The first state to achieve the transfer of all basic nurse education into the higher education sector, starting in 1985, was New South Wales. Twelve colleges of advanced education and one university offered the new, comprehensive, Diploma of Applied Science (Nursing) course. A further two colleges of advanced education, in which pilot programs for nurses had been offered, now dramatically increased their course intakes.
The 1989 abolition of the advanced education sector, and the establishment of the Unified National System of Higher Education, placed a question mark over the future of the newly established nursing diploma courses. It was finally proposed by the Australian Education Council that the initial qualification for those undertaking registered nurse education should be a three-year bachelor's degree. Efforts by the profession to secure a four-year (honors level) bachelor's degree as the norm were unsuccessful. The target year for all nursing programs in the higher education sector to be at degree level was set as 1992- a target that has now been reached (Nursing Education, 1994).
There is no national licensing examination in Australia. Each state or territory statutory authority accredits individual university programs that meet the specific requirements of that authority. Therefore, to gain registration as a nurse, applicants need to provide documentation to the statutory authority that they have completed an accredited program.
NEW ZEALAND NURSING EDUCATION
From the 188Os, nurses trained under the Nightingale model in English hospitals emigrated to New Zealand and introduced new standards of nursing (Kinross, 1984). In New Zealand, as in other Western countries, "a heavy emphasis on obethence as the first law of service to others was both an inspiration for, and the aim of, early nurse training" (Rodgers, 1987, p. 54). Following the New Zealand Nurses Act of 1901, New Zealand became the first country to register nurses.
Apart from an instance during the 1920s, when Otago University briefly offered a two-year diploma of nursing program, New Zealand had, up to 1973, one common curriculum for general nursing programs. This common core of "learning," audited by the Nursing Council of New Zealand, set the hours of practice and theory, and judged, through final examinations in medical-surgical and obstetrical nursing, the final outcomes for every student from New Zealand's 27 hospital-based training programs. Specialist preregistration programs in psychiatry, psychopaedic (nursing children with intellectual disability), and maternity nursing were also available separate from general nursing training.
By 1973, following an investigation by Eh-. Helen Carpenter, a Canadian nurse educator and a World Health Organization Consultant (Carpenter, 1971), nursing education was redirected away from hospital-based apprenticeships into polytechnics, institutions that catered for trades and design students. While Carpenter recommended that preregistration nursing education should be by undergraduate degrees it is only in the last two years that undergraduate degrees have been formally adopted as the basis of preregistration education. Since 1996, all 15 polytechnics offering nursing programs have been able to apply for degree-granting rights, and nursing diploma programs have been upgraded to degree programs. Nurses who gained diplomas prior to 1996 have the opportunity to enter a variety of programs of varying length at either polytechnics or at two universities, Massey and Victoria, to upgrade to degree status. Only the universities have the autonomy to select and monitor their programs. Polytechnic programs are subject to approval through the Nursing Council of New Zealand and a new infrastructure for universal education, the New Zealand Qualifications Authority. Following graduation, students are required to pass the state examination set by the Nursing Council of New Zealand.
UNITED KINGDOM NURSING EDUCATION
Early history of the "Nightingale" influence across the UK and the globe is well documented (BaIy, 1988). In the United Kingdom, hospital-based nurse training provided basic nursing education until the 1960s. In the early decades of the twentieth century, concerns over the lack of universal standards and the adequate supply of nurses were described in the Lancet Report (1932) and reinforced in the Wood Report (Ministry of Health, 1947). Recommendations for traditional student status emanated from the latter, which detailed the extreme levels of wastage and varying educational provisions in different hospital schools. Further developments in preregistration nursing education continued to be influenced, in the main, by concerns of recruitment and retention (White, 1985). The Royal College of Nursing (RCN) tended to push for reforms and more professional status while the General Nursing Council (GNC), founded in 1919 as the regulatory and registering body, tended to have a conservative influence. Resistance to raising entry criteria by the GNC in the belief that an inadequate number of recruits would be able to meet these requirements, proved to be mistaken. The policy, introduced in 1962, of requiring applicants to be either high school graduates or to have successfully completed a standard entry test, had a positive effect on numbers. Separate registers for the different nursing specialties, such as general and mental health, were maintained until the 1980s. Students were being prepared through different curricula and in many cases within different institutions.
Further pressure for better prepared nurses led to the RCN Platt Report (1964) that cited a number of initiatives within higher education for specialist and leadership programs, such as courses leading to degrees at the Universities of Manchester and Edinburgh. Nearly a decade later the government committee of nursing (Report, 1972) recommended a new statutory framework and educational policies. After some resistance and prevarication by government ministers, this led to the Nurses, Midwives and Health Visitors Act of 1979. The United Kingdom Central Council (UKCC) and the National Boards were then charged with setting and implementing standards and safeguarding the public. (The demise of the GNC occurred in 1983.)
Discussions with the UKCC, the National Boards and the Royal College of Nursing then reached consensus and gradually led to acceptance for the move of nursing education into higher education, "Project 2000: A New Preparation for Practice" (UKCC, 1986), a report authored by the UKCC that recommended three-year, university-based diploma programs, was accepted by the government and a relatively rapid transfer occurred out of hospital schools. Mergers of these schools and integration into universities has been completed in England and is in the process of completion in Scotland and Northern Ireland. A minority of Project 2000 three-year courses have been developed at the bachelor's degree level and, in parallel with the established four-year degree programs, have attracted good quality students. A diversity of provision for nursing education therefore exists.
At present the majority of students qualify at university diploma level after a three-year, full-time course that leads to registration in one of four branches: "Adult," "Mental Health," "Child," or "Learning Disabilities." The diploma programs differ from degree programs in that admission criteria are lees rigorous and studies are not as academic or indepth as in degree programs. A minority of courses lead to graduation at degree level after three years or three years plus a few months. These courses are fully funded by the National Health Service. In addition, the Higher Education Funding Council has funded (through 1998) universities that have four-year degree courses, the majority having been established in the late 1970s and early 1980s. The relative success of these programs provided evidence that higher education was appropriate and beneficial for nursing. Debate about the diploma or degree level of qualification is currently quite lively. The Royal College of Nursing has recently issued a pamphlet advocating three-year degrees for all entrants to nursing education (RCN, 1997). There is no externally set examination following completion of the degree or diploma programs; universities set their own assessments k tailored to the curriculum. The statutory body reviews these procedures.
Some universities are ambivalent about the standards achievable for the necessarily large number of nursing recruits. The nursing shortage (despite hospital closures) is translated into an annual increase in intake of new students (14% for 1997). Sustaining these numbers from - a shrinking pool is difficult and attracting more highly educated recruits ready for undergraduate studies is even more so. The post diploma, two-year, part-time specialist degree level courses capture those diploma graduates who wish to progress academically.
Postregistration professional development frameworks and regulations have been issued by the statutory bodies, for example the UKCC (1990). These provide an elaborate system for building on to initial registration with specialist pathways at degree level. Many institutions are now submitting curricula for these programs. However, the new Labor government returned to power in 1997 has a budget crisis and is likely to recommend a summer, more » cost effective system to set and implement educational and professional standards. Universities are now subject to much more stringent external quality monitoring and assessment by the Higher Education Funding Council.
In the UK, it has taken longer than in other countries to achieve full integration into higher education and some still remain ambivalent about the feasibility of all graduate entrants. This somewhat cautious approach is reflective of established elite institutions not wishing to alter standards or systems, since neither universities or hospital schools were in favor of this integration for some years. Persistent professional pressure associated with a valued nursing profession in the eyes of the public and a crisis in recruitment and retention could swing the pendulum.
UNITED STATES OF AMERICA NURSING EDUCATION
The early nurse training schools in the United States, opened during the 187Os, were modeled after ^ Nightingale's school in London. However, by 1893, when the American Society of Superintendents of Training Schools for Nurses was formed, the use of student nurse labor had resulted in an expansion of hospital-based training schools and educational standards had fallen. Concern among nursing leadership about the uncontrolled growth of nurse training schools was voiced in the 1923 report of The Committee for the Study of Nursing Education, known as the Goldmark Report. The committee members strongly recommended that endowment funding be secured for schools of nursing, and that endowed schools within universities should be established (Goldmark, 1923). In 1934, a second major analysis . of nursing in the U.S. by the Committee on the Grading of Nursing Schools recommended increased financial support for nursing education, a reduction in the number of nursing students, and replacement of student nurses by graduate nurses for hospital work (Committee, 1934).
Yet these scholarly endeavors were not responsible for the eventual shift away from hospital-based nurse training programs. The economic depression of the 1930s rendered graduate nurses inexpensive employees and many training schools were closed. Shortly afterwards, the introduction and acceptance of health insurance created a more stable hospital revenue that further increased graduate nurse employment (Fagin & Lynaugh, 1992; Lusk, 1995).
During the 1920s and 1930s, university baccalaureate degree programs for nurses were developed throughout the U.S. but did not expand as rapidly as nurse leaders had hoped. University administrators were cool to an influx of women wanting a professional, rather than a liberal, education. Additionally, nursing programs were expensive (Fagin & Lynaugh, 1992). In 1948, another major report on nursing education and practice, authored by Esther Lucilie Brown, again endorsed collegiate preparation for nurses. However, with few university programs and a post-war nurse shortage, the time was propitious for introducing nursing education in the less-expensive community colleges (Montag, 1959).
Community colleges, granting two-year associate degrees, were designed to facilitate post high school education for the middle and lower classes (Fagin & Lynaugh, 1992). In 1952, a research project to develop and evaluate associate degree programs in nursing was initiated at Teachers College, Columbia University, under the direction of Dr. Mildred Montag (Montag, 1959). The project was widely successful and community college programs proliferated. There were now three distinct educational programs: three-year hospital diploma, two-year associate degree, and four-year baccalaureate degree. All the programs prepared applicants to sit for the same licensing examination, necessary for nurse registration.
Reacting to this anomalous situation, delegates at the 1965 American Nurses Association (ANA) convention recommended that a baccalaureate degree should be the entry level standard for "professional nurses." Associate and diploma school graduates were to be called "technical nurses" (Kalisch & Kalisch, 1995). Over the last 30 years the entry into practice debate has continued but little progress towards the ANA's 1965 resolution has been made. North Dakota is the single state that requires a baccalaureate degree for entry ulto practice. In 1995, ANA delegates again resolved that action must be taken to implement the baccalaureate in nursing as the minimum level for professional RN licensure (ANA, 1995).
Several reports lent weight to the ANA's support of baccalaureate education. In 1990, a report to the President and Congress on the status of health personnel in the U.S. noted that the varied educational levels of nurses were out of balance with national needs. The report predicted a shortage of baccalaureate-prepared nurses by the year 2,000 and a surplus of associate degree and diploma graduates (Aiken & Gwyther, 1995). Two recent studies of nursing, under the auspices of the Institute of Medicine and the Pew Foundation, arrived at similar conclusions (Pew, 1995; Wunderlich, Sloan, & Devis, 1996). The Pew Foundation report recommended closure of up to 20% of diploma and associate degree programs (Pew).
The U.S. government has made some efforts to support nursing education. The 1964 Nurse Training Act, enacted during a nurse shortage, supported nursing education through financial support for nursing school construction, loans, and scholarships (Kalisch & Kalisch, 1995). The Medicare program, established by the Social Security Amendment Act of 1965 to provide health coverage for the elderly, has partially reimbursed hospitals for education of health care workers, including nurses (King, 1996).
Since 1994, there has been a decline in overall enrollment to all types of U.S. nursing programs (National League, 1997). However, there has been an increase in the number of registered nurses holding associate degrees or diplomas who are attending university to attain the baccalaureate level.
Of the three types of educational preparation, most RNs are from community college programs. In 1996, there were 876 two-year associate degree programs, 523 fouryear baccalaureate degree programs, and 109 three-year diploma programs hi the U.S. (National League, 1997). The number of diploma programs has declined precipitously during the last decades, from more than 900 during the late 1950s (National League), yet Medicare-generated money, a large source of support for basic nursing education, is still being entirely distributed to hospitals (Aiken & Gwyther, 1995; King, 1996).
The U.S. is currently experiencing dramatic changes in its health care system. Since people are discharged earlier in order to control costs, leading to a reduction in hospital bed requirements, there are decreased hospital employment opportunities for nurses but expanding community needs. Meanwhile, those in-hospital patients are more acutely ill than ever before and requiring highly educated caregivers. The diverse basic preparation of American registered nurses has been identified by some nurses as a significant barrier to nursing's advancement as a profession, yet the issue remains contentious (Jacobs, DiMattio, Bishop, & Fields, 1998).
These patterns of nursing education across three continents offer remarkable similarities. The international influence of Nightingale and the difficulties encountered as nursing education laboriously moves from hospitals to universities, via junior educational institutions, are common threads. As historian Charles Rosenberg wrote: "Every factor that had facilitated the creation of this novel enterprise [trained nursing] conspired ultimately to limit and constrain its professional horizons" (1987, p. 231).
Yet the 1980s and 1990s have generally been years of positive change for nursing education. Through fiscal mandates and awareness of nurses' educational rights, nursing students' service to hospitals has been almost completely abandoned. In Australia and New Zealand, nursing education has further evolved and is presently entirely at the baccalaureate level. In the United Kingdom, nursing education is in the process of completely moving into higher education with university-based diplomas, three-year, and four-year baccalaureate programs. In the United States, with its historic emphasis on individuality, nursing education remains divided. Hospital-based nursing education programs persist, although their number has sharply declined, and the majority of U.S. nurses graduate from two-year degree programs. However, nursing education in the United States is now primarily college-based and the American Nurses Association continues to lend its significant support to one entry level, a baccalaureate degree, for preregistration nursing education.
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Principal Academic Venue and Length of Prereglstration Nursing Programs